Manual Patient Result Forms
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Hello All! Looking for an effective way to manage manual POC test results at our clinic. Not all the areas perform the same tests, but there is some overlap. The final process is to scan the forms into the EHR. I'm trying to standardize and wasn't sure if one form with all tests available, or a seperate form for each test? Anyone willing to share some of theirs? Feel free to send offline. Thanks so much!!
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Amber,
My POC Assistant and I have just gone through the process of "standardizing" our result forms for all outside clinics. This was quite a task since we have approximately 22 clinics to manage and each needed their name and physical address. For some test, we were able to loose the patient logs, but still keep printouts for test and a QC log. For test that have an internal QC, we have to keep patient logs so we are able to prove the Internal QC is valid. Some clinics do many test and some not so many, and all enter results into "Alscripts" which go to the patient's EHR. We have different forms for each test and QC logs which include all relevant information; lot #'s, expiration dates. We have a large notebook (Document Control) and each form is stored electronically. Maybe a little overkill, but when I came into the position, the forms were all over the place and different for each clinic. This system has helped us a lot when we go out to review and check results every month also.
Good Luck,
Marcia
Hi Marcia,
I am going through the same thing you did, standardizing forms for multiple clinics. All of the clinics have paper logs for QC, but not all document patient results on paper. This means that tests with internal controls are not being documented with each patient. There is not a place in EPIC for them to document internal controls. It is required to have a paper record of patient results and internal control or can all of that be done in the EHR? Which tests were you able to loose the patient logs and why?
Thank you!
Kimberly
Kimberly:
We use EPIC and I had a separate result line added. The first is for the test result (positive or negative) and the second says Internal Controls Acceptable. I made it a hard stop. All they do is click in the field and it populates.
Lara
Hi Lara,
Thank you for the response! Do they still have to write the patient and internal QC results on a paper log? I thought about getting rid of the paper patient logs all together. If there are no paper logs how is it possible to do look backs?
Kimberly
Yes, we still have the paper logs for lot numbers and such. You could probably eliminate those if they recorded that information in the comments with each test, but what a nightmare trying to police that! I'm not sure it's worth it.
Lara
We also use Epic and have gotten away from paper logs as much as possible. We have Lab viewable only lines to enter the exp/lot#/ QC acceptable in and then just run a report each month to see if there were any discrepancies in the entered lot # or Exp. Its a hard stop to enter something but its not programmed to verify lot/exp since they change so often.
We still have a paper audit form in a few areas that print out a result and the analyzer (sofia and fetal fibronectin) are not hooked into the LIS.
Hi Renee, the manual tests that do not cross into LIS and that do not print out a result, such as hCG, are those results just entered into EPIC and not put onto a paper form?
We have no patient result paper logs for waived tests (no analyzer/ printout) such as SureView strep/. The lot# and exp with QC acceptable entry in Epic was deemed acceptable by committee and we have had no problem with it during any inspection. We do have Inventory logs with QC Completed entry that has the lot # of kit and QC and tech initials/date.
We only have an internal audit for possible transposition errors for analyzers that are not crossing to LIS.
Theory is you are looking at the kit test strip or cartridge as you are putting the interpretation into the computer and therefore shouldn't have one more step such as a log that could cause an error rather than catch it. Looking at the wrong line, or reversed numbers when you wrote it down.
Thank you for the information and your time Renne! I can see why you have eliminated paper logs. I have clinics that use paper logs and others that don't. Both sides have great points as to why they think their way is better. It now it is time for me to weigh the pros and cons. Thank you so much for your help!
Kimberly
didn't copy well but general idea.
Good Morning Kimberly,
We discontinued use of patient logs for any test that did not have an internal control. Losing the patient log for urinalysis results made our clinics very happy.....simply because of volume. We are in the early stages of a new IS for the hospital and all our clinics. Hopefully the issue of being able to enter internal controls can be addressed.....and we can lose ALL the paper logs!
Have a great day!
Marcia
Renee,
You mentioned that you have internal audits for possible transposition errors for anaylzers that are not crossing into LIS. How do you pull these reports in EPIC? You stated you are just looking to see if kit information is entered correctly such as lot number and expiration number. Because there are no patient logs there is no way to check to see if patient results were entered correctly. Is there a requirement somewhere that states patient or kit information needs to be checked by an audit? I am having a hard time finding any rules or standards related to waived testing and I just want to make sure all the bases are covered for inspections.
We don't have online internal QC for all of our POC tests but I'm working on it. I prefer to have Internal QC entered in the LIS over paper logs. There is no way around the LIS system. If you don't verify internal QC the system will not allow you to continue. This takes the worry out of compliance.
Do you have to enter the result and kit lot#, exp. date, and the two internal QC? That's a lot to enter for each patient test performed even for a low volume lab. Why not have a log for kit I nformation, i.e. date opened, lot# and exp. date and limit reporting to the test result, and internal QC checks?
If you are working with QC/ Calibration printouts from analyzers that are not interfaced, what have you found as the best way to organize and preserve those? Is there a special log you use to attached the prinouts? Do you have a log that they manually transfer the information and keep the printout with the log? I am in currently in the process of standardizing our practices and looking for the best way to streamline the various ways different areas have taken it upon themselves to track.